Consolidation

Consolidation - background
Pressure on pathology services to consolidate, reconfigure or modernise, whatever you prefer to call it, is nothing new. Lord Carter’s first reports, Independent Review of NHS Pathology Services in England, published in 2006 and 2008, recommended consolidation of services “to improve quality, patient safety and efficiency.” A key recommendation was the reinvestment of savings in the service. Despite significant savings having been made over the last decade, there has been limited evidence of reinvestment.

Lord Carter’s most recent report, Operational Productivity and Performance in English NHS Acute Hospitals: Unwarranted Variations, reiterated the call for consolidation, and NHS Improvement (NHSI) has called on trusts to draw up business plans, irrespective of whether services have already undergone consolidation or their host trusts already spend below the national average on pathology.  You can read our response to the Carter review here:

Consolidation - accounts 
Following recent discussions with NHSI and members, I started to pull together accounts of consolidation, both successful and unsuccessful, with the aim of developing a toolkit of examples of what has worked well and what hasn’t, to help those undergoing the process themselves. Unfortunately, but perhaps not surprisingly, few of the organisations where consolidation has been unsuccessful were prepared to share information about their experience. I therefore changed tack and invited members to write about their experience for The Bulletin. The first of these are available here: 

Consolidation – common themes
Not surprisingly there are some common themes emerging from the accounts received so far, most of which were highlighted in the College’s response to Lord Carter’s most recent report. To be fair, the 2008 Carter Report does say that investment in infrastructure, including IT and transport, is essential for successful consolidation. Unfortunately, this investment has not always been forthcoming, which may explain why several attempts at consolidation have failed recently.

Several members of the Pathology Alliance, which represents all pathology specialties and professional groups, recently attended the first meeting of the NHSI Pathology Optimisation Delivery Group, tasked with implementing Lord Carter’s recent recommendations on consolidation. Interestingly, the main presentation by NHSI highlighted the factors needed for this to succeed – and they were remarkably similar to the investment called for in the College response to the report and the common themes that have emerged from the pathology services that have undergone successful consolidation. It is heartening to learn that NHSI recognises the significant investment that will be required to deliver the desired efficiencies. The Pathology Alliance commits to working with NHSI to achieve the best outcome for patients.

Consolidation – reliable data
One of the concerns the College raised about enforced consolidation was the lack of reliable data on which to base decisions. This is highlighted in the 2nd Atlas of Variation in NHS Diagnostic Services in England, published in January, which contains no pathology or genetics because “the data could not be accessed”.

Unlike the first Atlas, it contains only imaging, endoscopy and physiological diagnostics. It is reassuring to read that one of the first things NHSI has done is to collect data from all pathology services. This is very much needed, both in terms of workforce and workload.

Although  reliable  data  is  essential,  it  is  important  that  staff  work  rates  are  not  measured purely in terms of the volume and complexity of samples processed. This does not recognise much of the vitally important work done by staff such as teaching, training, research, quality assurance, quality   improvement, management, leadership, and regional and national work for the wider NHS. NHS Digital’s standardised test list will aid comparison of workload. It will not, however, replace the currently stalled National Laboratory Medicine Catalogue (NLMC), in which the College and NHS England  have  invested  considerable  time,  expertise and money. It is somewhat comforting to read about the National Pathology Handbook that has been introduced in Wales drawing heavily on the work done in England on the NLMC. Ireland has also based its new national pathology IT sys tem, MedLIS, on the catalogue. 

Consolidation – information technology
Recognition by NHSI of the importance of joined-up IT systems is welcome but not particularly reassuring. New laboratory information management systems (LIMS), and the professionals to support them, are expensive and few labs can afford to update what they’ve got, let alone start from scratch with a completely new system. Unless central funding  is  identified  to  resource  shared  LIMS  across networks, consolidation plans are doomed to fail. Several recent high profile examples of problems with  LIMS  have  highlighted  the  importance  of having  reliable  pathology  IT  provision,  but  that costs money and won’t be introduced overnight.

Consolidation – key messages
Consolidation doesn’t always save money, at least not in the short term. All the featured successful reconfigurations have required significant investment, often in new buildings. As Dr Gareth Bryson says of his experience in Glasgow, “merging for financial reasons alone is unlikely to result in long-term stability and success”.

The College has always argued that  there  is no single solution for all pathology disciplines and geographical locations. Dr Esther Youd says in her description of the Wales experience, “Consolidation success looks different in different specialties. There is no one model which fits all.” Professor Jo Martin highlights the emotional link that many members of staff have to their work-place and comments that “the ultimate outcome of short-term cost savings can be long-term losses in terms of recruitment and morale”. While there are economies of scale in large departments, the workforce remains key to the provision of a high quality service and should not be forgotten or taken for granted. Staff buy-in is clearly essential.

Despite the challenges, consolidation has been a positive experience for our authors. I hope that you will find these accounts informative and helpful. I also hope that they will stimulate discussion and encourage others to share their experience. The topic of consolidation will be continued in the July issue of The Bulletin so please do let us know of your experience. You can email me at president@rcpath.org

Dr Suzy Lishman, President, The Royal College of Pathologists
April 2017